“Structuralism” is the excessive focus in the physical therapies on crookedness or “mechanical” problems in the body — what I call the biomechanical bogeymen. It is the source of much bogus diagnosis — things like tilted pelvises, short legs, abnormal spinal curvatures, or “misaligned” anything — and the cause of much therapeutic barking up the wrong tree. Such factors are much less important than many people still believe.
Structuralism has been challenged by many medical researchers and experts like Dr. Lorimer Moseley Moseley, Dr. Scott Dye (knee surgeon); or back experts Drs. Richard Deyo, John Sarno, and Nickolai Bogduk; soft tissue pain experts like the late Dr. Janet Travell, Drs. David Simons and Seigfried Mense (see Muscle Pain), or Dr. Chann Gunn, and on and on.
Many key scientific studies over the years have undermined major structuralist assumptions, like Finan’s finding that knee pain correlates more with pain sensitivity than arthritis; Grundy’s conclusion in Lancet that short leg length differences don’t correlate with back pain; or Grob’s findings that abnormal neck curvatures do not predict neck pain; or Moseley’s finding that a placebo for knee osteoarthritis is just as good as real surgery; or numerous MRI studies showing terrible correlation between structural problems and back pain (see Boden, Jensen, Weishaupt, Stadnik, Borenstein); or the astonishing finding by Haig that even narrowing of the spinal canal does not necessarily cause stenotic back pain; or the clear evidence that even dislocation of the upper cervical spine is often asymptomatic (Swinkels); and so on (and on and on).
Almost everyone who has ever been to any kind of physical therapist or doctor for a stubborn pain in their body, some injury-like breakdown, has been told that they are deformed and fragile — probably not in those words, but that’s the gist. Just as acupuncturists can be counted on to blame most problems on a blockage of chi, freelance manual therapists in particular1 tend to blame pain on “mechanical” or “structural” problems that might be repaired by pulling or pushing on the flesh:
… and a long list of more technical-sounding problems such as tibial torsions, steep Q-angles, and many more absurd examples.2 Some of these may well be valid. For instance, I have a minor but definite deformity in my right foot that has certainly caused me some muscle fatigue and pain in that extremity.3 In spite of this personal experience, modern scientific evidence clearly shows that the importance of most bio-“mechanical” problems has been greatly exaggerated. There are at least five major problems with these kinds of diagnoses:
Even if we were to overlook the two former hurdles, there is yet a third one to overcome—are manual techniques or specific exercises effective in modifying inherent postural-structural-biomechanical factors? Can foot mechanics, leg length differences, pelvic tilts, vertebral positions and spinal curves be permanently changed, solely, by these clinical tools?
To understand injuries and pain problems and to recover from them more effectively, both patients and professionals need to stop trying to think of the body as a machine that breaks down, and start thinking more in terms of squishy, messy physiology, especially neurology and biochemistry.
“Structuralism” is my own term for the excessive focus4 in the physical therapies on postural and biomechanical factors in pain problems — the biomechanical bogeymen. In its most simplistic form, structuralism fixates on just one or two biomechanical factors as the wellspring of most or all pain. For example, I know one extreme example: a therapist who earnestly believes that the stability of the cuboid bone — a foot bone the size of a sugar cube — is the key to all pain and its relief. That’s absurd.
And I know another therapist who believes that he has identified the source of “all pain,” namely a consistent pattern of postural dysfunction that is caused by Coriolis force, of all things — the effect of the spin of the earth on currents in the ocean and atmosphere, the cause of storm spin (but not of the direction of water circling a drain — that’s a myth, it doesn’t work on small scales). He told me, with a straight face, that this pattern of dysfunction “should be the opposite Down Under”!6
But structuralism definitely isn’t just for health professionals with the weakest and strangest ideas. Many orthopaedic surgeons, physiatrists, and sports medicine specialists are also keen structuralists. Most chiropractors are structuralists, almost by definition. The great majority of physical therapists and massage therapists are inclined to structuralism. The Functional Movement Screen™ (FMS) is an extremely conventional, popular new method of “effortlessly identifying asymmetries and limitations”7 which is routinely used (and abused) to justify treatment — a perfect example of structuralism right in the middle of the mainstream.
These professionals are not all united, and subscribe to a many different flavours of structuralism. For instance, many doctors disdain chiropractic structuralism — but in place of poorly defined chiropractic “intervertebral subluxations,” physicians ironically put forward their own more scientifically respectable biomechanical factors. But while doctorly structuralism is less anti-scientific in tone and substance than a lot of chiropractic philosophy, unfortunately that doesn’t necessarily make it any more correct. Just as the manual therapies are infested with all kinds of biomechanically inspired treatments, so to there has been an epidemic of dubious orthopedic surgeries to “correct” every imaginable kind of structural problem: different expressions of structuralism.“Structuralism” is an excessive preoccupation with biomechanical bogeymen.
I will show that most structuralism is barking up the wrong tree. This isn’t a scholarly article, but it is heavily referenced — there are plenty of citations to credible and interesting scientific research, linked and summarized.
A patient once gravely informed me, as if sharing a dangerous secret, that a chiropractor had predicted his back pain by identifying a minor leg length difference ten years earlier. The prediction was a warning: get your short leg fixed, or else you’ll be laid low by low back pain for sure!
Such a prediction is about as insightful as predicting death, taxes, or the rising of the sun. Back pain is one of the most common afflictions in the modern world. An impressive 90% of all people will have an episode of acute back pain at some point in their lives … whether they have a “short leg” or not.
“The warning” is the most common way that structuralism can do harm. It is often a part of the sales pitch for a structural diagnosis. It simultaneously offers the client a pleasingly simplistic explanation for their pain, and yet it also manages to frighten patients into paying for therapy for the wrong reasons. Much worse, and ironically, it can probably frighten them right into real pain or pain chronicity, in some cases, via a nocebo effect — the opposite of a placebo.8 The prevalence of such scare tactics is why I originally coined the term “biomechanical bogeymen.”
I remember how I annoyed I was at the fact that [this Rolfer] thought he “knew” what was wrong. He told me to stop walking like an old man — like I was just assuming some contorted posture when I could be standing straight and tall if I just decided to, like I had become that way because I had started to think of myself as an old man and so became one. He literally believed that!
reader Harry M
Most of the bogeymen exist so that freelancer therapists have something to chase for pay. With low to zero diagnostic reliability, diagnoses like “shoulder dyskinesia” — fancy talk for bad shoulder movement — are clinically trivial and have more to do with sounding good than actually knowing anything helpful, so a professional can stare at your shoulder for a while and wisely declare, “Well, there’s your problem,” as though it were obvious. To an expert.
This is an extremely cynical viewpoint, of course, but I cannot overstate how common it is for therapists to make the entire treatment encounter revolve around the idea of identifying and finding and exorcizing structural flaws, and how happy patients generally are to pay for it. (I’ll return to this question of how common it really is.) I just got an entire earful of an example at random just a couple days before I wrote this, from an acquaintance who doesn’t even know what I do for a living. She described in reverential detail exactly that kind of appointment — in which a patient with normal shoulder movement and no shoulder pain actually paid an osteopath to fix her “dislocated” shoulder.9 Countless times I’ve listened to patients tell stories about their biomechanical diagnoses, almost literally brainwashed by structuralists,10 seriously saying, believing that their severe pain is the consequence of an “alignment” problem so subtle that you’d be hard pressed to detect the deviation with a microscope. Nobody older than thirty would be able to walk if such trivial defects could really wreak such havoc.
People who have terrible body pain problems often have perfect posture, good ergonomics, and healthy joints — bodies that are basically in great condition. Meanwhile, many people with perfectly obvious biomechanical problems — everything from significant scoliosis to obesity — are doing just fine, thank you very much. For instance, a 2012 study clearly showed that severity of pain simply did not match up with the severity of degeneration.11 This inconsistency is so glaring that it’s puzzling that so many professionals seem to ignore it. Why? How can they miss it?
Simple: unfortunately, it pays to miss it. It pays to pathologize.
Clinicians fail to notice the inconsistency because they would like “something to fix” and to get paid for fixing it. If the definition of “normal” was widened (as it should be), there would be fewer “problems” to diagnose, less to seem wise and knowing about, and less therapy to recommend to the customer. Natural biomechanical diversity undermines clinical mojo. So it’s not in the best interests of therapists to “normalize” patients and describe their anatomical quirks as harmless, but quite the opposite! It’s better for egos and incomes to define “normal” more narrowly, and place blame on anything odd, giving naive customers the impression of cleverness for identifying an idiosyncratic cause of trouble.
It is difficult to get a man to understand something when his job depends on not understanding it.
The Upton quote could not possibly be more applicable. Adapted slightly: It is difficult to get a therapist to understand that structural abnormality is rarely meaningful when his job depends on ignoring this data and actually emphasizing structure.
And of course there’s also just good ol’ confirmation bias. Once you start mentally leaning towards the idea of asymmetries as a major cause of pain, you start noticing and emphasizing only the cases that seem to confirm that expectation … and ignoring the ones that contradict it. Nobody older than thirty would be able to walk if such trivial defects could really wreak that kind of havoc. Health care is so full of puzzles that it’s effortless to write off anything that doesn’t confirm your bias as an inexplicable oddity — you can even claim humility, shrug, confess “I don’t know,” even as you conveniently dismiss data that could have taught you something.
The basic problem with structuralism is that biomechanical factors have surprisingly little to do with pain problems. The two things correlate poorly. But structuralism is deeply embedded in our cultural consciousness, and we cling to the idea that aligned and symmetrical must be the best way way to be, and we suffer in proportion to our deviations from that diagram. That equation makes intuitive sense to us, and we’re just not going to give it up easily!
I enjoy “pathologizing” posture. It gives me a sense of purpose.
Les Glennie, Registered Massage Therapist (yes, tongue in cheek)
Don’t take my word for it, for goodness’ sake. There is a lot of hard evidence and the most expert possible opinions to back me up.
Patient complaints that originate in the musculoskeletal system usually have multiple causes responsible for the total picture.
Structuralism has been shunned by many medical researchers and experts. For instance, San Francisco orthopaedic surgeon Dr. Scott Dye has written eloquently about how ill-advised structuralism is when it comes to knee pain.12 Eyal Lederman, a UK osteopath, wrote a particularly persuasive article criticizing the postural-structural-biomechanical model13 — an article much like this one, but much more academic and technical. (For balance, I will also cite the extensive rebuttals to that article published in the Journal of Bodywork & Movement Therapies in 2011.14) Foot, shoe and orthotics expert Benno Nigg wrote an entire book15 about how poorly structuralism has stood up over time. In a 2011 paper, “The Modernisation of Manipulative Therapy,”16 Australian physiotherapist Max Zusman writes:
Research indicates that, despite physiotherapists’ comprehensive training in the basic sciences, manipulative (currently “musculoskeletal”) therapy is still dominated in the clinical setting by its original, now obsolete, structure-based “bio-medical” model. more“This is further inexplicable in the light of evidence that not only the underlying “philosophy” but also several of the fundamental requirements of the clinical process itself which has the structural-mechanical model as its basis, have been shown to be flawed or at least irrelevant. The apparent inability of the profession to fully abandon outmoded “concepts” (and embrace the acknowledged science-based “best practice” biopsychosocial model) may have potentially undesirable consequences for both patients and therapists engaged in the management of (chronic) musculoskeletal pain and disability.”
Back pain experts Drs. Richard Deyo17 and Nickolai Bogduk18 have virtually devoted their careers to teaching doctors not to overestimate the importance of biomechanical factors in back pain. Bogduk writes concisely: “‘Degenerative disc disease’ conveys to patients that they are disintegrating, which they are not. Moreover, disc degeneration, spondylosis and spinal osteoarthrosis correlate poorly with pain and may be totally asymptomatic.”
Dr. John Sarno’s career has also been about debunking structuralism in back pain.19 In 1984, he first wrote:
There is probably no other medical condition which is treated in so many different ways and by such a variety of practitioners as back pain. Though the conclusion may be uncomfortable, the medical community must bear the responsibility for this, for is has been distressingly narrow in its approach to the problem. It has been trapped by a diagnostic bias of ancient vintage and, most uncharacteristically, has uncritically accepted an unproven concept, that structural abnormalities are the cause of back pain.
Mind Over Back Pain, by John Sarno, p112
If not structure, then what? Neurology and homeostasis. Another Australian, sassy pain researcher Dr. Lorimer Moseley, has been doing excellent research and “outreach” on this topic for years now, constantly encouraging clinicians to understand pain not as an inevitable consequence of biomechanical stresses and tissue trauma, but as an output of the brain strongly affected by many considerations — many of which have nothing to do with issues in the tissues.20 In particular, “The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).”21 — and if pain chronicity can’t even be explained by tissue pathology in these common conditions, it’s not very likely that subtle biomechanics can fill in that blank.
And there are tissue issues that may have little or nothing to do with structuralism at all. In 2011, biologist Paul Kubes published fascinating evidence that inflammation may become chronic due to a glitch in human immune systems.22 Dr. Janet Travell, Dr. David Simons and Dr. Siegfried Mense made significant scientific contributions toward understanding the more subtle and complex alternatives to structuralism, especially the ways that muscle might hurt more or less “spontaneously” — due to neurological and/or metabolic dysfunction — perhaps causing a lot of the chronic pain that would normally be attributed to biomechanical bogeymen. Simons in particular wrote extensively and passionately about the neglect of this important subject:
Muscle is an orphan organ. No medical speciality claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain, and medical students and physical therapists rarely receive adequate primary training in how to recognize and treat myofascial trigger points.23
Many key scientific studies over the years have undermined major structuralist assumptions. Some of the evidence is direct. Some is indirect, or “circumstantial,” as a criminal lawyer would put it. There is a strong pattern of all kinds of evidence converging on the same conclusion: structuralism does not produce effective therapies. It does not “deliver the goods.”24
My favourite direct evidence — not the best, but my favourite — has always been the simple leg length study published way back in 1984, in the venerable British medical journal Lancet. It showed that leg length differences were unrelated to back pain — no correlation even, let alone a causal relationship.25
The fear of an excessive curve in the low back, AKA the pelvic tilt myth, has spawned countless back pain “cures” based on stretching and strengthening to try to flatten it out a little, with the (coincidental I’m sure) bonus of flattening bellies at the same time. This is a well-studied question, and a 2008 systematic review of more than 50 studies found no association between measurements of spinal curves and pain.26 If there is any connection, it’s a weak one.
An excellent example is a failure of the Functional Movement Screen to detect actual recent injuries, let alone a subtle or specific biomechanical risk factor for injury. As mentioned in the introduction, FMS is a set of physical tests intended to “identify asymmetries and limitations,” based on the assumption that they are a problem — classic structuralism. However, a 2011 study in the International Journal of Sports Physical Therapy found that FMS test results didn’t change in people who had actually been injured within the last six months.27 If a test can’t detect the effect of recent injury on the body, or the risk of factors that led to it, it probably can’t detect future injuries either, and the structural assumption at the heart of FMS is therefore rather dubious.
The neck is a popular place for biomechanical bogeyman, but in 2007 Grob et al published findings in the European Spine Journal that abnormal neck curvatures do not have any connection with neck pain.28
Or the shoulder? “Shoulder dyskinesis” — fancy talk for bad shoulder movement — is a popular biomechanical bogeyman in this area, but is rather dubious. There’s definitely no smoking gun evidence that funky shoulder movement leads inexorably to pain, and a nice fresh 2013 review in the British Journal of Sports Medicine concluded “no physical examination test of the scapula was found to be useful in differentially diagnosing pathologies of the shoulder.”29 (Funny story about that citation, too.30)
Perhaps the knee? Devan et al published in the Journal of Athletic Training that they couldn’t find any connection between knee injuries like iliotibial band syndrome and patellofemoral pain syndrome and any of the mechanical “usual suspects” that are blamed for those conditions.31
A bizarre and amazing study published in the New England Journal of Medicine in 2002 showed that a placebo for knee osteoarthritis is just as good as real surgery.32 A more “mechanical” problem than rough knee cartilage can hardly be imagined, yet 150 people who received a sham surgery recovered just as well as people who actually got their cartilage polished. It’s hard to imagine a more crushing blow to structuralism!
Numerous MRI studies of the back over the years have shown just terrible correlation between structural problems and back pain.33 Time after time, you find that people with low back pain have no mechanical problems, and people with mechanical problems have no low back pain.
Surely narrowing of the spinal canal is always painful? Perhaps not. Cranking up the counter-intuitiveness another notch, scientists found in 2006 that a structural problem that everyone previously assumed to always be painful — even I thought so! — turns out not to be. Spinal stenosis has always been regarded as an inevitable cause of back pain, but the Archives of Physical Medicine & Rehabilitation has showed clearly that it often does not cause pain after all.34
Poor correlation in animals, too! Here’s an interesting perspective from veterinarian Johnny Bat-Yonatan on canine hip dysplasia, an arthritic condition common in big breeds like Labrador retrievers, German shepherds, and rottweilers:
It’s a horrendous thing that often leads to the animal having to be euthanised, but the highly specialised grading of hip dysplasia doesn’t correlate directly with mobility and life quality. You have great x-rays of animals that can barely walk, and horrendous hips in dogs that don’t display any pain. X-rays sometimes tell a story, other times they’re a footnote. We learn early that we need to treat the animal, not the radiograph.
“Treat the animal, not the radiograph.” Nicely put, and equally apt for pets and their humans. We’re all animals! For more information, see Canine Hip Dysplasia, by Wendy Brooks, DVM, DipABVP.
If spinal instability were painful, surely stabilizing it would help? But a 2009 study showed that “stabilizing” fractured vertebrae by injecting bone cement doesn’t actually aid the recovery — at all!35 If such a straightforward method of stabilization doesn’t work, it’s pretty hard to make the case that instability could have been much of an issue in the first place.
A blow to the importance of muscle “balance” — symmetrical muscle mass and strength — was delivered by the British Journal of Sports Medicine in 2010.36 First the authors proved that major muscle imbalances do exist in elite Aussie-rules football players — bigger kicking muscles on one side — and then proved that they were “not related to the number of injuries” in those athletes. I repeat: Not. Related. This is exactly the opposite of what any good structuralist would predict.37
Pronation is one of the greatest hits of structuralism, so prevalent that it’s routine to hear runners call themselves “pronators,” and it’s easy to see why: surely the ankle collapsing inward is a recipe for repetitive strain disaster? Not so much, and a number of lines of evidence have suffocated the idea over the years. A major (final?) blow landed in 2010 when American Journal of Sports Medicine published a huge study showing that shoes to control pronation had no effect on injury rates in US Marines.38 It wasn’t quite the right study to prove specifically that pronation doesn’t cause injury, but it certainly proved you can’t control it with the right shoe — which is really the only way most people ever try to control it. There is no justification for ever labelling anyone as a dirty rotten pronator.
Core strength is still assumed to be important by nearly every professional and patient,39 and yet it has been thoroughly debunked by one experiment after another for twenty years now. No kind of core training has any special power over back pain, cannot produce any benefit greater than minor or greater than any other kind of therapeutic exercise, and does not reduce injury rates. This is all covered in much greater detail in my low back pain book.
My favourite recent example of core strength research is a 2010 study of more than 1,100 soldiers which found that specialized, “precise” core strengthening did little to improve rates of low back pain (or any other injury) compared to good old-fashioned sit-ups.40 Meanwhile, many other studies show that no kind of core strengthening is important.41
A large 2011 study of massage therapy for low back pain42 tested the effectiveness of a “structural” style of massage consisting of a blend of popular techniques and treatment approaches based on common structuralist assumptions. Massage therapists are prone to believing that “the right moves” will have a more profound therapeutic effect.
Moderately-trained therapists with more than five years of experience provided about 130 patients with 10 hours of this kind of massage. They also gave ordinary relaxation (Swedish) massage to another 130 patients. The effects on back pain of these two approaches were carefully measured over an entire year. The results were revealing: there was “no clinically meaningful difference between relaxation and structural massage” whatsoever! That is quite an embarrassing outcome for techniques that are routinely touted as “advanced.” If structuralism were a good basis for massage technique, shouldn’t it have produced impressively superior results?
My personal experience in studying this subject for the last several years is that I can hardly look anything up anymore without finding more evidence that structuralism is just generally a poor way of explaining people’s pain.
Of course, biomechanical factors are relevant to some injuries and pain problems. Ask anyone who has had a ruptured tendon. Structuralism is, by the definition I’ve given it, an excessive preoccupation with biomechanical factors.
Biomechanics do matter sometimes.
For instance, it is an anatomical fact that women have larger, stronger posterior lumbar joints,43 which is almost certainly a biomechanical feature that has evolved to cope with fairly major combined stresses of a large, awkwardly off-centre weight and leaning backwards to keep from falling over. This pretty strongly suggests that women with weaker spines, over the aeons, often failed to carry their babies to term because the strain was debilitating.
What are the odds that this evolutionary adaptation makes women immune to the back strain caused by pregnancy? Well … nil! Even today, even with tougher spines, pregnant women suffer increased rates of low back pain.
What we take from this is that the importance of spinal curvature is moderated by evolution. We can clearly see that deviations from normal spinal curvature are a factor in back pain, or women would never have evolved an adaptation to cope with it. On the other hand, the same adaptation pretty clearly shows that both men and women are probably adapted enough that spinal curvature alone cannot be a “deal breaker” — if it were, we would have evolved to cope with it.
Another way of putting it: evolution doesn’t care if you have back pain, just as long as you can breed … but it always makes sure that you can do at least that much. What are the odds that this evolutionary adaptation makes women immune to the back strain caused by pregnancy? Well, nil …It is easy for nature to saddle us with biomechanical features that are uncomfortable and imperfect, but at the same time we are mostly well-protected from biomechanical features that are routinely crippling.
Thus biomechanical factors are usually much less important than is generally supposed.
But structuralists aren’t all wrong or always wrong, of course. Some biomechanical bogeymen truly are scary, and there are times for a structural diagnosis, and a structural solution. Some problems are clearly more “mechanical” in nature than others — and the menisci in the knee are an awesome example of a high-functioning but vulnerable evolutionary compromise. Medical researchers have had no trouble confirming that … or demonstrating the correctness of the theory by devising therapies and surgeries that fix the problem. Indeed, it is the power of such treatments that has in part made a structuralist view of other pain problems so attractive.
Yet there is no doubt in my mind that the evidence leads us away from getting our knickers in a collective knot over most of the popular structuralist theories.
There is a flavour of structuralism for every degree of gullibility, I’m afraid.
“Upper cervical” (NUCCA) chiropractors believe that nearly all problems not only originate solely in the top-most spinal joint, but that they have the skill to reliably correct all of these problems by manipulating that joint. This is hard for many people to swallow, but there is still clearly a market for the service — many patients are charmed by such an elegant-seeming explanation for everything that’s ever gone wrong with them.
Savvier patients are still likely to fall hook, line, and sinker for exactly the same kind of thinking when they encounter it in a massage therapist’s office. A short leg diagnosis certainly sounds like a plausible explanation to a lot of people. Only a few more cynical patients will dismiss it. More than a few times people have come to me rolling their eyes about the short leg diagnosis, usually because they simply failed to get any benefit from the therapy … and they felt cheated.
But even a hardened skeptic will often happily swallow a dubious structural diagnosis when it comes from a doctor reviewing an MRI report — indeed, they will probably swallow it because it comes from a doctor reviewing an MRI report! Unfortunately, the source doesn’t make it any more true.
For instance, your sports medicine specialist is often just as wrong as any other structuralist, and nothing has done more to perpetuate this problem than magnetic resonance imaging: a space age technology that is incredibly persuasive, yet can easily be misinterpreted. Science itself has shown countless times that MRI results can and routinely are misunderstood by doctors — in particular, MRIs often reveal harmless structural features and abnormalities that get blown way out of proportion. Gosh, that high-tech medicine sure is persuasive!
Structuralism is immune to credentials. Everyone’s got the disease of structuralism, both alternative health professionals as well as defenders of the mainstream alike.
It’s time for some examples …
It’s important to understand that there is not really any particular reason for us to believe that we will easily find good advice about aches, pains and injuries. Unfortunately, most patients seeking care for a knee problem or a shoulder problem don’t realize at first that it may be surprisingly difficult to get good help. If their problem proves to be a stubborn one, it may take them several months or even years before they become more cynical and savvy. Along the way, they invariably encounter a lot of structuralism, which they slowly but surely become more and more suspicious of — yet they will lack the expertise to challenge it.
In the following section I will try to address the question of how common structuralism really is. (Hint: dang common.)
I once worked with a back pain client who had seen at least two dozen structuralists over a period of five years. Literally every health care professional he had seen was a dyed-in-the-wool structuralist, and his mind was quite polluted with their theories: he could hardly open his mouth without saying something about his alleged biomechanical problems. Predictably, there was no agreement between the various diagnoses — everyone had diagnosed a different biomechanical bogeyman. What a mess! So I was thrilled to hear that he had just started seeing a new doctor who was — like me — telling him to stop worrying about biomechanics.
But it took this patient five years of searching to find just two non-structuralists! We were the first he’d ever encountered.
Family doctors have a proven poor track record in these matters — musculoskeletal medicine, that is.44 They really know quite little, and so they fall into the mental convenience of structuralism easily, just because they’ve never really thought about it one way or the other. And orthopaedic surgeons are (appropriately) preoccupied with building their surgical expertise, and so their knowledge is quite naturally slanted towards structuralism.
Chiropractors are structuralists pretty much by definition: the profession exists to “adjust” alleged biomechanical problems with the spine and other joints.
Physical therapists (physiotherapists in Canada) are notorious for their preoccupation with the mechanics of the body. I believe that they have fallen into this trap because they do not have clearly defining methodology. Massage therapists massage, chiropractors crack, surgeons cut … but what do physiotherapists do? They are generalists, cherry-picking from a wide variety of therapies, such as strengthening exercises or ultrasound treatments. This is both an obvious strength and a weakness. I have often had the impression that physiotherapists quite literally focus on structuralism because it gives them something to do — something to diagnose, something to therapize, a nice clear theme for their choices.
Massage therapists are not well-trained in most jurisdictions — and even where training standards are higher, massage therapists barely scratch the surface of rehabilitation science — and so they tend to fall into structuralism because they lack the education they need to deconstruct it, and embracing it is the easiest way for them to feel more competent. For instance, “diagnosing” and “treating” postural dysfunction is an easy way to sound like you’re providing “medical massage.” The unfortunate reality is that most massage therapists, although their work may produce many minor benefits (see Does Massage Therapy Work?), simply do not have the academic chops to even try to explain complex musculoskeletal problems.
Sports medicine specialists and physiatrists are the most likely source of competent medical help for aches, pains and injuries. They are the best-trained, and the most likely to be keeping up with the science. However, their practices are also usually dominated by major traumatic injuries — knees that are “blown” in football games, that sort of thing. They provide invaluable services to these patients, but just like your family doctor is out of his depth when you develop vague symptoms, these specialists often don’t have much to offer patients who aren’t concretely injured. They may dismiss such problems as trivial, or they may humbly recognize that they simply don’t know what to do with them, or a bit of both. Chronic overuse injuries that just won’t go away, back pain that comes and goes mysteriously, severe neck cricks … these are common problems, yet they are also considered “problem cases” at most sports medicine clinics. I often see patients with these problems who have been to see two or three specialists, all of whom were basically stumped: they tossed out a few structuralist explanations — “Well, it’s probably got something to do with your core strength. Let’s get you to the gym…” — and then they seemed to lose interest.Chronic musculoskeletal pain problems are also considered “problem cases” at most sports medicine clinics.
Who does that leave? What kind of professional is likely to look for explanations more complex and less satisfying that the easy but incorrect answers of structuralism?
The sad, ugly truth: no kind of professional. There simply is no such critter. You simply have to find an individual professional who cares, someone who is a determined, humble and open-minded troubleshooter, someone isn’t obsessed with structuralism. It’s a tall order!
A common complaint about this article is that I make a straw man argument: a case against an imaginary kind of professional. Hardly anyone is actually a structuralist, the argument goes, and no good professional really exaggerates the importance of biomechanical factors. Ironically and absurdly, the same accusers usually then go to angrily defend their own pet structuralist therapy from my criticisms.
This topic is highly controversial, and has sparked heated debates in every possible context, from scientific journals to Facebook. The majority of the social media kerfuffles I’ve seen — and I’ve seen hundreds — have been fights about the validity of one structuralist sacred cow or another. Numbers are impossible (without some research that won’t ever be done), but my experience strongly suggests that structuralism is not only common but still the dominant way of thinking about musculoskeletal pain. And I’m hardly alone in that opinion. Here’s a supportive reader report from the UK:
Lederman’s “The Myth of Core Stability” has been available on our physiotherapy website for years, and yet I still hear the same old core stability nonsense churned out on a daily basis. My biggest gripe is why the universities (over here in England anyway) keep on teaching the same old syllabus, and don’t evolve their courses in line with current evidence. There is still a huge emphasis on passive treatments and different ways in which we can ‘fix’ our patients it’s scary. And until we start to produce physios with a different schooling and a different mindset, unfortunately I can’t see there being much of a paradigm shift in the near or distant future.
Pete Gray, Physiotherapist, Nottingham
Maybe there are significant differences between professions in different parts of the world.45 But here in my own backyard — and damn near everywhere else, as suggested by a decade of constant substantive correspondence with patients and professionals around the world — structural and biomechanical factors generally reign supreme, routinely emphasized by manual therapists to the near exclusion of most other therapeutic considerations. I have seen a never-ending parade of clients with biomechanical past diagnoses, but (almost) never seen a patient who said, “Well, the last guy emphasized psychosocial factors and central sensitization neurology!” Which should be the rule, not the (vanishingly rare) exception.
Instead, while many non-biomechanical factors in chronic pain may be paid some lip service, they are rarely/barely used to actually guide clinical choices. Merely mentioning them does not constitute useful application of the evidence to a patient’s difficult situation. Few clinicians seem to be aware of that evidence, fewer still seem to know what to do with it — and so they continue to strongly favour biomechanical factors.
As Leon Chaitow writes:46
… no remotely intelligent practitioner or therapist actually believes that all pain and dysfunction is caused by structural features alone, this is hardly a balanced approach. … Ignoring biomechanics/posture/structure would therefore be as ludicrous as suggesting that back pain (or other) was solely due to biomechanical factors.
Indeed it would. But, unfortunately, I’ve observed much more lip service to the idea of “balanced approach” than a genuinely balanced approach. Professor Gordon Waddell is a low back pain expert and one of the pioneers of alternatives to structuralism, and was writing about “treating patients rather than spines”47 way back in the 80s:
It is all very well to say that we use science and mechanical treatment within a holistic framework, but it is too easy for that framework to dissolve in the starry mists of idealism. We all agree in principle that we should treat people and not spines, but then in daily practice we get on with the business of mechanics.
Gordon Waddell. The Back Pain Revolution. 1998.
So this isn’t a new problem, I’m afraid. I am even guilty of over-emphasing structural factors myself. I know how tempting a perspective it is. I was taught to treat people with my hands, and I still tend to think like a sculptor of flesh — a meat repairman — regardless of whether that actually makes any sense. I strain to prevent that way of thinking from dominating, but I have often failed. I have often made the error of fixating on that which is more concrete and easier to hold in my mind, easier to explain to patients, easier to chase with my hands.
You can’t “grab” a psychosocial factor! And so most health professionals have a strong and understandable mental predisposition to structuralism.
Yes, well of course, and that’s all fine and good, but don’t throw the baby out with the bathwater.
most of the world’s manual therapists, before getting back to biomechanical business as usual
One particularly insiduous sub-species of structuralism involves elaborate “dot connecting” theories. Most structuralism takes the form of straightforward causes like “a narrowed spinal canal causes back pain” (it doesn’t; again see Haig et al). Structuralism tends to be presented this way even when the biomechanics are obviously not that simple.
But professionals who really embrace structuralism like to “connect the dots,” the better to impress their patients. For instance, a podiatrist might tell you that your fallen arches (dot!) cause greater strain in your knees (dot!), which in turn force you to use your hips differently (dot!), which leads to hip weakness (dot!), then muscle imbalance in the core (dot!), which finally results in back pain (dot!). The best dot connectors can be quite convincing, painting elaborate pictures of interconnectedness and inviting you to share a wise chuckle about how “everything really is connected.”
Indeed, the foot bone really is connected to the leg bone, and so on. That these kinds of more complex biomechanical relationships exist is not in question — they do. The trouble is that they are hopelessly complex, effectively impossible to interpret reliably, extremely difficult to treat … and, above all, simply not all that important.
Recall that we have already demonstrated that even simple biomechanical relationships do not correlate well with pain. A narrow spinal canal does not predict stenotic back pain. Many people with ITB syndrome do not have a tight ITB. And so on. Even the most direct relationships tend to defy common sense. The relationships exist, yes, but it turns out that they are fiendishly hard to understand.
Every time you add another link in the chain of reasoning between a symptom and its proposed cause, you increase the complexity and the chance of error exponentially. Considering that therapists often cannot even agree on the existence or clinical significance of a single biomechanical factor, what are the odds that they are going to agree on the causal relationships between three or more of them?
Therapists use dot-connecting structuralism to impress their patients … and themselves. The dot-connecting thing is usually inextricably connected with an ego trip. This is explored more thoroughly in the article The Humble Therapist.
Why are patients so tolerant of structuralism? Why do they so consistently believe something that is so easy to disprove? Something that doesn’t even produce results?
Because it is human nature to believe whatever feels good.
Given the choice to believe in something that feels good but is wrong, and something that is true but is not comforting to believe, the human animal will go with whatever “feels good” almost every time. This tends to result in the proliferation of every imaginable kind of product, service and scam that appeals to our desires. We actually do constantly spend time and energy on “solutions” that don’t work — whether it’s a kitchen widget, a stock tip, or physical therapy. Knowing what we all know about human nature, it would be amazing if we weren’t collectively prone to excessive optimism about health care theories.
Carl Sagan’s book, The Demon-Haunted World, thoroughly and brilliantly illuminates this principle of human nature, giving countless examples of how belief and gullibility is driven by our craving to live in our comfort zone.
And, when you really believe that something “makes sense,” you will probably spend a long time looking for evidence that you are correct, even when you can’t find any. Your comeuppance will be delayed for years, or even your entire life, by a strong tendency to misinterpret the evidence in your favour. Usually only young upstarts can look at the situation and see the problem clearly. I am just cocky enough to say that I am that guy — or at least I was when I wrote the first draft of this article, many years ago. I am old enough now to have read a great deal of science, vastly more than the average clinician, and there’s simply nothing there to support structuralism as a broadly useful way of thinking about pain problems, and it’s really obsolete in certain niches (low back pain!), and out in left field in others (upper cervical chiropractic, or NUCCA).
After decades of trying, researchers still can’t find the phenomena that they obviously think “must” exist for structural explanations of pain to work. And, meanwhile, clinicians keep repeating the explanations!
Both patients and professionals are suckers for structuralism for two reasons:
But the body is assuredly not just a complicated machine. Mechanical imagery is almost completely useless in musculoskeletal health care. By analogy, doctors have learned that there is a great deal more to an obstructed artery than “clogging” — instead, it involves a bewildering array of chemistry mediated by countless factors, a mess the likes of which no one dreamed possible a hundred years ago.
Similarly, therapists must get past mechanics. Joints may be like hinges in a superficial way, but they are not hinges, work nothing like hinges, and fail nothing like hinges. Yet structuralism is a rather transparent and pathetic attempt to explain pain as a failure of a machine, described in terms that are quite simplistic compared to the breathtakingly complex reality that is your tissues.
Posture, structure and biomechanics have had their day in the research sun; they have had their chance to make a difference. We’ve wrung almost as much explanatory power and clinical relevance out of that paradigm as we’re ever going to. The returns on our research investment started diminishing long ago, and we’re down to dregs and subtleties. Meanwhile, overuse injuries and chronic pain march on, just as nasty as ever before, and probably much worse. It is time to move on to new ways of explaining and treating pain.
I have received many cranky complaints over the years about this article, and most of them have called me out for failing to provide any alternatives to structuralism. However, it isn’t my responsibility to tell professionals what should replace a failed conceptual model. It’s a big enough job just making the case that the emperor has no clothes — picking out a new wardrobe for him to wear tomorrow isn’t feasible, and doesn’t make him any less naked today. And what if nothing in particular can replace structuralism? The truth is important on its own, no matter how depressing.
Fortunately, I do think there are straightforward clinical alternatives to structuralism. I spent at least the last few years of my own career as an extremely busy massage therapist, helping people every day but only occasionally motivated by ideas about structural causes of pain. I don’t think it was all that difficult.
Most manual and manipulative therapy for at least a quarter century has had the same goal — alter the state of peripheral tissues, because of the guiding principle that there must be something wrong with those tissues. Most of that work is done in vain, because there is rarely anything wrong of that sort (or nothing that can be manipulated into shape, at any rate). And yet repair is often attempted at the cost of a bunch of caustic sensory input — because trying to fix flesh often involves uncomfortable tactics. (Luckily for patients, their brains generally interpret those sensations as “good for me, no pain no gain,” consider them safe, and so surprisingly little harm is done, and sometimes even some good, albeit largely accidental good. But there also many exceptions to that: some people are downright traumatized by the tough love of intense, meat-manglin’ therapy48)
The main problem with the focus on changing tissues is usually just a missed opportunity — the opportunity to spend hands-on time doing stuff the nervous system might actually enjoy. And perhaps find useful.
Avoid pain and nocebo, create novel and pleasant sensations, and be an expert guide and coach. In more detail:
I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.
I received a note from a reader — allegedly a colleague and kindred spirit. He thanked me for my writing, and then asked:
Would you like to know what actually causes trigger points? I have been at this for twenty years and have the answers that we all search for.
Uh oh. Clearly, this is someone who fancies himself a “healer” with special knowledge — almost certainly a structuralist theory. His delusions of grandeur are betrayed not only by his belief that he has “the answers that we all search for,” but by his teasing lack of detail. If he really has special knowledge, why would he ask me if I want to know? Why wouldn’t I? Why be guarded or vague? Just share! Can you imagine a scientist writing to another scientist and saying, “Would you like to know how things really work?”
I decided to bite, just to see what he would say, and his reply was vain and vague, with hand-waving references to an “amazing” therapeutic protocol that can work marvels with pain patients, and all of it depending on something — he doesn’t say what — in the feet. This is classic wind up for a doozy of a structural theory to explain all pain. For structuralists, “it all” always hinges on one critical biomechanical factor.Can you imagine a scientist writing to another scientist and saying, “Would you like to know how things really work?”
I pointed out that his lack of humility, lack of detail, and lack of scientific evidence was all fairly off-putting. And this was his reply, pitch perfect for a delusional “healer.” I have reproduced it here word for word, because it is just such a gloriously irritating example of this kind of thinking, which is absolutely rampant in alternative health care:
I appreciate what you are saying, I have been humble for 2 decades now, in fact this has been my ministry for 20 years. As I have said I don’t have all the answers and I don’t have a panacea for anything, neither have I cured anything, I’ve worked with many alternative types of medicine and have used these methods to end my own bout with cancer. What makes my method work is a complimentary adjustment top to bottom. What makes the adjustment stay is the cuboid [a small foot bone] being held in place. If you have the skills needed to reduce or eliminate the scoliosis then you can appreciate that just to get proper treatments in some areas, you have to fight. I am entirely guilty of being an old warrior, who finally has won. I don’t need to argue any more, I demonstrate. I have no desire to change the way things are, only to save as many as I can. Technical explanations are good for conversing with doctors, but my mission is to communicate with the average joe who has been through the “mill” and has lost hope, these are my flock. To check out my “ extraordinary claims” You will find confirmation in Dr. Warren Hammers book entitled; Soft tissue examination and treatment by manual methods pg 425.
There are so many things about his thought process that are disturbing that I hardly know where to begin, but here are the highlights:
And a final dig I can’t resist…
This is why so many doctors so reasonably object to alternative medicine: because it is, so often, so disappointingly ego-driven.“I have been humble for 2 decades now” is not an expression of humility.
This article was many years old before I started logging updates in Apr, 2010. It’s date of origin is lost. It probably evolved out of several other article written between about 1998 and 2003.
Wednesday, July 9, 2014 — Added interesting perspective from veterinary medicine: as with humans, correlations between structure and pain and disability in animals are poor.
Tuesday, December 24, 2013 — Added evidence that being a dirty rotten pronator is … no big deal. Also (finally) added a concluding section about alternatives to structuralism.
Thursday, December 12, 2013 — Added a quote from a professional reader supporting my opinion of the prevalence of structuralism.
Tuesday, October 23, 2012 — A thorough, modernizing edit and general cleanup. A number of references added, a few tired and weaker ones removed.
Wednesday, March 21, 2012 — Added evidence that lumbar curvature doesn’t matter.
Friday, August 12, 2011 — Added an important new reference about “structural” massage for low back pain.
Saturday, July 9, 2011 — Added information about Functional Movement Screening, based on Schneiders et al.
Thursday, April 21, 2011 — Added much more detail to the example of my own deformed foot.
Sunday, April 17, 2011 — Some revision to the introduction to make it more readable and interesting.
Tuesday, December 28, 2010 — A correction: Australian League Football is not “soccer.” Thanks to Nick A. for the heads up on that. And some clarification of the evidence concerning muscle asymmetries and injury rates in players.
Monday, August 23, 2010 — Added some thoughts about the prevalence of structuralism, inspired by a Facebook discussion with some colleagues.
Tuesday, May 11, 2010 — An extensive edit for humour, charm and accuracy. Several references were upgraded, Diane Jacobs’ wonderfully sassy definition of structuralism was added to the introduction, and Dr. Eyal Lederman’s brilliant essay is now prominently recommended: “The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain”.
Wednesday, April 7, 2010 — Added quite a few thoughts about how professionals are able to overlook obvious observations that contradict their beliefs about structuralism.
In my view all upper quadrant injury except for the hands comes down to the inability of the body to control scapular depression. It is also my view that all injuries of the lumbar spine and lower extremities are due to the inability to perform a kinesiological squat.
One can’t help but wonder what all hand problems are attributed to! The absolutism here is glaringly arrogant and nonsensical, the thinking of low calibre — for instance, there is no such thing as a “kinesiological squat” — but this is alarmingly typical of structuralist theories.BACK TO TEXT
This article is a bloody brilliant deconstruction of the underlying assumptions of the vast majority of pseudo-quackery in the manual therapies. It’s technical and academic, not for the lay reader, but absolutely required reading for professionals. Be sure to read his other excellent essay, “The Myth of Core Stability”.BACK TO TEXT
This classic, elegant experiment found no connection between leg length and back pain. Like most of the really good science experiments, it has that MythBusters attitude: “why don’t we just check that assumption?” Researchers measured leg lengths, looking for differences in “lower limb length and other disproportion at or around the sacroiliac joints” and found no association with low back pain. “Chronic back pain is thus unlikely to be part of the short-leg syndrome.” Other studies since have backed this up, but this simple old paper remains a favourite.BACK TO TEXT
This review of more than 50 studies found no association between measurements of spinal curves and pain. The authors’ conclusion was decisive: the evidence “does not support an association between sagittal spinal curves and health including spinal pain.” One can cherry pick the data for a few studies that show some minor correlation, but it averages out to nothing to write home about.BACK TO TEXT
According to the authors of this study, the Functional Movement Screen™ (FMS) is “based on the assumption that identifiable biomechanical deficits in fundamental movement patterns have the potential to limit performance and render the athlete susceptible to injury.” However, this small, high-quality experiment could not even detect a difference in test results in people who had actually been injured recently: the results “demonstrated no significant differences on the composite score between individuals who had an injury during the 6 last months and for those who had not.”
On the bright side, this study did confirm that the FMS testing is reliable (inter-rater reliability): different professionals get almost exactly the same results. It also produced good baseline test results for average active people, which is an important first step in helping professionals (and future researchers) start to understand the meaning of FMS results — if any.
For more detailed analysis of this, see The Functional Movement Screen (FMS).BACK TO TEXT
In this study, about 150 people were assessed for back pain in different ways, including MRI, but “radiologic and clinical impression had no relation.” In other words, there was no useful similarity between evaluation of the patient with MRI, and evaluation by examination and taking a history. “The impression obtained from an MRI scan does not determine whether lumbar stenosis is a cause of pain.” Since MRI does in fact identify narrowing of the spinal canal, and this is the whole basis of diagnosing spinal stenosis with MRI, these results also strongly imply that a narrowed spinal canal does not (alone) cause back pain.BACK TO TEXT
This study presents strong evidence that there is “no beneficial effect” to stabilizing fractured spines with injections of bone cement (vertebroplasty), a common and apparently dubious procedure. The frequency of this “surgery” — though it is usually performed by surgeons, it’s just an injection — will now drop off dramatically, as surgeons demonstrate that they respect the evidence (when good science shows that something doesn’t work, doctors stop doing it).
The evidence is also a poetic addition to the evidence that spinal fragility is not the cause of back pain. If stabilizing the spine with cement doesn’t resolve symptoms, it strongly suggests that instability wasn’t the problem to begin with.
Strictly speaking, the only thing this evidence can tell us is what it told us: patients with osteoporotic fractures who got vertebroplasty recovered no better than those who only thought they got vertebroplasty. But the rationale for vertebroplasty has always been cave-man simple: Ooog. Vertebrae busted. Hurt. Thag make stronger. Inject glue. Ugh. Supposedly these fractures are painful because the spine is unstable — hardly an unreasonable assumption — and therefore stabilizing them will help. Except it didn’t! Not in these patients.
So maybe it’s not the instability that’s causing all the pain.
For a much more detailed analysis of this, see Dr. David Gorski’s excellent article on the subject.BACK TO TEXT
Researchers used MRI to measure the size of kicking muscles in 54 Australian Football League players — very serious athletes, these guys, playing a very rough sport — and found that “asymmetry of the psoas and the quadratus lumborum muscles exists in elite AFL players.” Such asymmetries are widely believed by therapists to be clinically significant. Manual therapists, if they suspected such a distinct asymmetry in muscle mass, would enthusiastically and almost unanimously embrace this significant lack of “balance” as a major risk factor for injury, and a likely suspect in whatever injury or pain problem a person might happen to be experiencing.
However, the researchers also found that “asymmetry in muscle size was not related to number of injuries.”BACK TO TEXT
Can a custom shoe prevent injuries by compensating for individual differences in running mechanics? Several hundred Marine Corps recruits were given motion control, stability, or cushioned shoes for their “low, medium, or high arches.” Those recruits got injured just as much as hundreds of other recruits who were given stability shoes, regardless of their arch shape. It’s a large, good quality experiment that clearly establishes that prescribing special shoes “based on the shape of the plantar foot surface had little influence on injuries.” What “Big Ortho” doesn’t want you to know!BACK TO TEXT
This survey of 600 Irish physiotherapists showed that advice and exercise were the treatments most frequently used for chronic low back pain. Advice was most commonly delivered as part of an exercise programme, and strengthening (including core stability) was the most frequently prescribed exercise type.BACK TO TEXT
An excellent summary of medical knowledge of low back pain. Waddell is a respected authority in the field, and a good writer.This is one of the earliest anti-structuralism papers I’m aware of. BACK TO TEXT